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Chapter 3 • Affective Changes 41
https://t.me/med1917
in response to a chronic stressor or one that has enduring consequences.
The disorders in this category can present themselves quite differently. The key to diagnosis is to examine the issue that is causing the adjustment disorder
and to determine the primary symptoms associated
with the disorder (e.g., anxiety or depression).
Anxiety Disorders
There are several types of anxiety disorders and multiple diagnoses. An anxiety disorder should not be
confused with everyday stress and worry. Anxiety disorders are persistent conditions that require careful diagnosis. Anxiety is a group of disorders characterized
by a number of both mental and physical symptoms,
with no apparent explanation. The primary feature is
abnormal or inappropriate anxiety. Apprehension, fear
of losing control, fear of going “crazy,” fear of impending danger or death, and uneasiness are among the
most common psychological symptoms. Common
physical symptoms include dizziness, lightheadedness,
chest/abdominal pain, nausea, increased heart rate, and
diarrhea.
Generalized Anxiety Disorder
Chronic anxiety, also referred to as generalized anxiety disorder, manifests as persistent worries, fears,
and negative thoughts lasting a minimum of 6 months.
Excessive worry over daily activities and a tendency
toward headache and nausea are seen. Typically, generalized anxiety disorder (GAD) develops over a period of time and is not noticed until it is signicant
enough to cause problems with functioning. Anxiety
is persistent, pervasive, and occurs in many different
settings.
Panic Disorder
Panic disorder is manifested by sudden attacks of fear
accompanied by symptoms that resemble a heart attack
(e.g., palpitations, chest pain, dizziness). Often the
symptoms develop rapidly and without an identiable
stressor. The individual could have had periods of high
anxiety in the past, or could have been involved in a
recent stressful situation; however, the underlying
cause is typically subtle. Panic attacks subside as
abruptly as they begin, typically lasting a few minutes,
although they can last several hours. The patient could
have thoughts of impending disaster, which can lead
to repeated emergency medical presentations. The
frequency of these attacks can vary from several times
a day to only once or twice a year.
Social Phobia (Social Anxiety Disorder)
Symptoms include extreme anxiety and fear associated
with social or performance situations in which the patient
is exposed to unfamiliar people or to scrutiny. The patient
recognizes that the fear is excessive or unreasonable but
avoids the social or performance situations or endures
them with intense distress or anxiety.
Mood Disorders
Mood disorders contain several categories, including
dysthymia, depression, and bipolar disorder.
The disorders in this category include those in
which the primary symptom is a disturbance in mood
with inappropriate, exaggerated, or a limited range
of affect. The feelings are extreme, pervasive, and
unrelenting.
Dysthymia
The patient experiences feelings that are less intense
than major depression but still disrupt everyday life.
The patient experiences a depressed mood for most of
the day and for more days than not, for at least 2 years.
During this time, there must be two or more of the following symptoms: undereating or overeating, sleep
difculties, fatigue, low self-esteem, difculty with
concentration or decision making, and feelings of
hopelessness.
Major Depressive Disorder
The hallmark symptom of depression is either a depressed mood or a loss of interest or pleasure in usual
activities. Major depression can signicantly impair a
person’s ability to function in family, work, and social
situations. Patients with depression experience deep,
unshakeable sadness and diminished interest in nearly
all activities. Crying and feeling depressed or suicidal
occur frequently.
Bipolar Disorder
Bipolar disorder has two types. Bipolar I disorder
requires the occurrence of at least one manic episode
even though other episodes, such as major depressive,
hypomanic, or mixed, could have occurred. Bipolar II
disorder requires at least one hypomanic episode.
Mania is sometimes referred to as the other extreme
of depression. The patient experiences an elevated,
42 Chapter 3 • Affective Changes
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expansive, or irritable mood with behaviors and symptoms that reect a “high.” The symptoms are sufcient
to interfere with usual social activities and relationships with others.
In bipolar II disorder, there are periods of highs,
as described previously, often followed by periods of
depression. The high episodes are hypomanic rather
than manic. The symptoms are similar but are not
severe enough to cause marked impairment in social
or occupational functioning and typically do not
require hospitalization to ensure the safety of the
person.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Psychological Disorders
CONDITION HISTORY PHYSICAL FINDINGS
Normal
stress
Normal grief Loss of someone or something of
Domestic
violence
Substance
use
disorders*
Perceived stress related to external or
internal stressors, such as daily life
events or situations, psychological
environments, relationships
Can be acute or chronic
Can feel unable to cope or adapt
Can have mental, physical, and
behavioral symptoms
importance
Can have physical and psychological
symptoms
Mood fluctuations; feels depressed
Can have difficulty functioning
Reports physical, sexual, psychologi-
cal, emotional, or economic attacks
from family or partners
Could seek care frequently for undi-
agnosed psychosomatic concerns
Could report suicide attempts
Reports recurrent substance use
that results in failure to fulfill major
obligations at work, school, or
home and substance-related legal
problems
Use in situations that are
physically hazardous (e.g., driving
while intoxicated)
Continued use despite significant
social or interpersonal problems
caused or exacerbated by effects
of the substance
Report increased tolerance of and
need for increased amounts of
substance
Report withdrawal symptoms
Report unsuccessful efforts to cut
down or control substance use
Could appear unkempt, with unusual
dress
Could have depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Adolescents could show evidence of
cutting
May appear unkempt, with unusual
dress, general state of poor nutrition
Depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Speech could be soft and monotonous
with little spontaneity
Adolescents can show evidence of
cutting
Can have injuries inconsistent with
history
Adolescents can show evidence of
cutting
Skin can be cold and clammy, itching
and burning, tight, swollen, or puffy
Excess perspiration
Discolored fingers or injection marks
along the veins
Tattoos or burn marks, injuries or bruises
Methamphetamine users can have
self-induced facial lesions secondary
to scratching
Eyes can be injected, jaundiced, puffy,
or glassy
Pupils can be dilated or constricted
Eyelids can be droopy with sleepy
appearance or fixed stare
Can have difficulty controlling eye move-
ments
Can have chronic rhinorrhea, lesions in
the nose or around the nostrils
Can have dry lips, halitosis, or an odor of
alcohol, marijuana, or tobacco
DIAGNOSTIC
STUDIES
None
None
None
Toxicology screen
Blood alcohol level
Chapter 3 • Affective Changes 43
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DIFFERENTIAL DIAGNOSIS OF OF Common Causes of Psychological Disorders—cont’d
DIAGNOSTIC
CONDITION HISTORY PHYSICAL FINDINGS
Autism
spectrum
disorder
Anxiety Disorders
Adjustment
disorder*
Generalized
anxiety
disorder*
Panic
disorder*
Lack of language developmental
milestones; could lose language
skills; social interaction lacking
The development of emotional or
behavioral symptoms in response
to an identifiable stressor(s)
occurring within 3 months of the
onset of the stressor(s)
Distress that is in excess of what
would be expected from exposure
to the stressor
Significant impairment in social or
occupational (academic)
functioning
Excessive anxiety and worry for most
days of past 6 months, about a
number of events or activities (such
as work or school performance)
Difficult to control the worry
Associated physical symptoms, such
as restlessness, edginess, fatigue,
difficulty concentrating, irritability,
sleep disturbance
Significant impairment in social,
occupational, or other areas of
functioning
Recurrent unexpected panic attacks:
discrete period of intense fear or
discomfort with physical symp-
toms, such as palpitations, pound-
ing heart, or accelerated heart rate,
sweating, trembling or shaking,
sensations of shortness of breath
or smothering, feeling of choking,
chest pain or discomfort, nausea or
abdominal distress, feeling dizzy,
unsteady, lightheaded, or faint,
paresthesias, chills or hot flushes
Report fear of losing control or going
crazy, fear of dying
Persistent concern about having
additional attacks
Lack of eye contact, might not smile,
does not respond to name with hearing
intact
None Refer for psychological
Behaviors such as finger tapping and
pacing that indicate anxiety
Adolescents could show evidence of
cutting
None except during attack Refer for psychological
STUDIES
CHAT screening
Refer for
developmental and
cognitive evaluation
evaluation
Refer for psychological
evaluation
evaluation
Continued
44 Chapter 3 • Affective Changes
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Psychological Disorders—cont’d
DIAGNOSTIC
CONDITION HISTORY PHYSICAL FINDINGS
Social
phobia
(social
anxiety
disorder)*
Mood Disorders
Dysthymic
disorder*
Major
depressive
disorder*
Marked and persistent fear of one or
more social or performance
situations
Anxious about acting in a way that
will be humiliating or embarrassing
Report panic attack related to
exposure to the situation
Avoids the situation
Avoidance, anxiety, and distress
interferes significantly with the per-
son’s normal routine, occupational
(academic) functioning, or social
activities or relationships
Depressed mood for most of the day,
for more days than not, for at least
2 years
Reports symptoms of depression
such as appetite and sleep
disturbance, low energy or fatigue,
low self-esteem, poor concentra-
tion or difficulty making decisions,
feelings of hopelessness
Reports acute symptoms of
depressed mood most of the day,
nearly every day, or loss of interest
or pleasure in all or almost all
activities of the day, nearly every
day
Experiences other symptoms most
every day such as appetite
disturbance, sleep disturbance,
psychomotor agitation or
retardation, fatigue or loss of
energy, feelings of worthlessness
or excessive or inappropriate
guilt, diminished ability to think or
concentrate, recurrent thoughts of
death or suicide
None Refer for psychological
Can appear unkempt, with unusual
dress; general state of poor nutrition
Depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Speech can be soft and monotonous
with little spontaneity
Adolescents could show evidence of
cutting
Can appear unkempt, with unusual
dress; general state of poor nutrition
Depressed demeanor
Facial expression (e.g., dejected, sad,
downcast)
Tearing, crying
Speech can be soft and monotonous
with little spontaneity
Adolescents could show evidence of
cutting
STUDIES
evaluation
Refer for psychological
evaluation
Serum electrolytes
CBC
Thyroid function tests
Refer for psychological
evaluation
Chapter 3 • Affective Changes 45
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Psychological Disorders—cont’d
DIAGNOSTIC
CONDITION HISTORY PHYSICAL FINDINGS
Bipolar
disorder*
CBC, complete blood cell count; CHAT, Checklist for Autism in Toddlers.
*For specific diagnostic criteria, see Diagnostic and statistical manual of mental disorders, ed 4, text revision, Washington, DC, 2000, American
Psychiatric Association.
History of at least one manic episode
or hypomanic episode
A distinct period of abnormally and
persistently elevated, expansive,
or irritable mood, lasting at least
1 week
Accompanying symptoms of
inflated self-esteem or grandiosity,
decreased need for sleep, more
talkative than usual or pressure to
keep talking, insomnia or hypersomnia nearly every day, psychomotor agitation or retardation,
flight of ideas or racing thoughts,
easy distractibility, increase in
goal-directed activity, excessive
involvement in pleasurable activities
that have a high potential for painful
consequences
Report history of one or more major
depressive episodes (see above)
In mania, the speech can be rapid,
pressured, and loud, and the speech
content consists of a flight of ideas
STUDIES
Refer for psychological
evaluation
REFERENCES AND READINGS
Diagnostic and statistical manual of mental disorders, ed 4, text revi-
sion, Washington, DC, 2000, American Psychiatric Association.
Baird G, Charman T, Cox A, Baron-Cohen S, Swettenham I,
Wheelwright S: Current topic: screening and surveillance for
autism and pervasive and developmental disorders, Arch Dis
Child 84:471, 2001.
Bastiaens L, Francis G, Lewis K: The RAFFT as a screening tool for
adolescent substance use disorders, Am J Addict 9:10, 2000.
Carlat DJ: The psychiatric review of symptoms: a screening tool for
family physicians, Am Fam Physician 58:1617, 1998.
Citrome L, Goldberg JF: The many faces of bipolar disorder: how to
tell them apart, Postgrad Med 117:15, 2005.
Dosreis S, Weiner CL, Johnson L, Newshaffer CJ: Autism spectrum
disorder screening and management practices among general
pediatric providers, J Dev Behav Pediatr 27:88, 2006.
Dunphy LM, Winland-Brown JE: Primary care: the art and science
of advanced practice nursing, Philadelphia, 2001, FA Davis.
Ewing JA: Screening for alcoholism using CAGE. Cut down, annoyed,
guilty, eye opener, JAMA 280:1904, 1998.
Feldhaus KM, Koziol-McLain J, Amsbury HL: Accuracy of 3 brief
screening questions for detecting partner violence in the emergency department, JAMA 277:1357, 1997.
Goldenring J, Rosen D: Getting into adolescent heads: an essential
update, Contemp Pediatr 21:64, 2004.
Goolsby MJ, Grubbs L: Advanced assessment: interpreting nd-
ings and formulating differential diagnoses, Philadelphia,
2006, FA Davis.
House A, Stark D: Anxiety in medical patients, BMJ 325, 2002.
Johnson CP: Recognition of autism before age 2 years, Pediatr Rev
29:86, 2008.
Lieberman JA III: BATHE: an approach to the interview process in
the primary care setting, J Clin Psychiatry 58:3, 1997.
Mersy DJ: Recognition of alcohol and substance abuse, Am Fam
Physician 67:1529, 2003.
Snyderman D, Rovner BW: Mental status examination in primary
care: a review, Am Fam Physician 80:809, 2009.
Sokol RJ, Martier SS, Ager JW: The T-ACE questions: practical
prenatal detection of risk-drinking, Am J Obstet Gynecol 160:863,
1989.
Stein M: Attending to anxiety disorders in primary care, J Clin
Psychiatry 64:35, 2003.
Whooley MA, Avins AL, Miranda J, Browner WS: Case-nding
instruments for depression: two questions are as good as many,
J Gen Intern Med 12:439, 1997.
Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M: Rational
clinical examination. Is this patient clinically depressed? JAMA
287:1160, 2002.
C H A P T E R
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4
Amenorrhea
menorrhea is a lack of menstruation that can
be the result of primary or secondary causes.
A
of menarche by 16 years of age with normal pubertal
growth and development, the absence of menarche by
14 years of age with lack of normal pubertal growth
and development, or the absence of menarche 2 years
after sexual maturation is complete. Primary amenorrhea is a rare condition, with constitutional puberty
delay the most common cause. One third of primary
amenorrhea cases are genetic in nature, such as Turner
syndrome or abnormality of the X chromosome.
menstruation for at least three cycles in women with
established normal menstruation or 9 months in females
with previous oligomenorrhea (menstrual periods occurring at intervals of greater than 35 days, with only four to
nine periods in a year). The most common causes of
secondary amenorrhea are the physiological events of
pregnancy, lactation, and menopause.
outow tract, a hormonally responsive uterus, and an
integrated hypothalamic-pituitary-ovarian (HPO) axis.
An important task in the diagnostic evaluation of amenorrhea is to identify the malfunctioning element. The
primary care provider begins investigation of etiological
reasons for amenorrhea and uses that knowledge to determine the type of amenorrhea. In turn, the suspected
cause guides diagnostic tests, treatment, and referrals.
This method of classication directs the clinician to
evaluate constitutional causes, congenital or chronic
disorders, the lower genital tract, and then dysfunction
of any component of the HPO axis.
satile delivery of gonadotropin-releasing hormone
(GnRH) by the medial-basal hypothalamus. In response, the posterior pituitary releases luteinizing
hormone (LH) and follicle-stimulating hormone
(FSH). These inuence the growth and development
of a follicle and its release of estradiol, which causes
46
Primary amenorrhea is dened as the absence
Secondary amenorrhea is dened as the absence of
The production of menstrual ow requires an intact
The normal menstrual cycle begins with the pul-
the uterine endometrium to proliferate and initiates
the LH surge, which is followed by ovulation and
menstruation (Figure 4-1 and Table 4-1).
The hypothalamus is also affected by the central
nervous system (CNS) and the thyroid gland, which
can determine the amount of GnRH received by the
pituitary. Alterations in the pattern of GnRH pulsatile
release decreases circulating LH and FSH levels;
the consequence is an anovulatory menstrual cycle and
amenorrhea.
About 66% of all amenorrheic women are hypoes-
trogenic because of either hypothalamic-pituitary hypofunction or end-organ failure. Determining whether
the patient is hypoestrogenic can expedite nding the
reason for her amenorrhea and setting the sequencing
of laboratory tests. The progesterone challenge test
(PCT) causes withdrawal bleeding if there is estrogen
production and an adequate outow tract. The functional status of the pituitary-ovarian unit is assessed by
measuring the gonadotropins (LH and FSH).
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is there a pregnancy?
Key Questions
n Are you sexually active?
n Are you using any birth control methods?
n Are you trying to become pregnant?
Pregnancy
For any female with a uterus, it is important to rule out
pregnancy as the rst step in determining the cause of
amenorrhea. It is rare, but a young girl can become
pregnant before the onset of menses. Pregnancy should
be ruled out before the administration of androgenic
challenge tests. If the woman is pregnant and there is
accompanying bleeding, determination of whether the
pregnancy is uterine or ectopic is the next priority (see
Pituitary gland
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Anterior
Hypothalamus
Posterior
Chapter 4 • Amenorrhea 47
Within CNS
Follicle-stimulating
FSH
Primary follicle Graafian
Menstruation
1st day 5 10 14 25 28 1st day
FIGURE 4-1 Interrelationships among cerebral hypothalamic, pituitary, ovarian, and
uterine functions throughout the menstrual cycle. (Modified from Lowdermilk DL, Perry
SE, Bobak IM: Maternity & women’s health care, ed 6, St Louis, 1997, Mosby.)
Estrogen
Proliferative phase
Resting
phase
follicle
Ovulation
Chapter 33). Be cognizant of domestic violence and
sexual abuse, with consequent unintended pregnancy.
Ask direct questions in private about being hit, pushed,
or slapped or about having nonconsensual sex.
Luteinizing
LH
Within ovary
Corpus luteum
and some estrogen
Secretory phase
Progesterone
Degenerating
corpus luteum
Menstruation
Within
uterus
bleed after androgen challenge tests are most successfully treated by an infertility specialist. Young maternal
age and early referral to a specialist increase a woman’s conception rate.
Contraceptive Use
The type and use patterns of contraceptives are important
in the search for the cause of amenorrhea. Contraceptive
failures can account for an unintended pregnancy. Amenorrhea can occur after discontinuation of oral contraceptives. Measurement of serum gonadotropins is affected
by long-acting contraceptives, such as Depo-Provera
(medroxyprogesterone acetate [DMPA]), implants, or intrauterine devices (IUDs) containing progestagens; these
must be discontinued before testing.
Seeking Pregnancy
Knowing that the patient is seeking pregnancy or, if the
patient is pregnant, whether it is intended or unintended allows the interview to be structured appropriately. It also aids in proper counseling and referral.
Amenorrheic patients seeking pregnancy who do not
Is this primary or secondary amenorrhea?
Key Questions
n Have you ever had a menstrual cycle?
n Have you started pubertal development? Can you
show me how your breasts and pubic hair (PH) look
compared with these pictures? (Use Tanner Sexual
Maturity Rating [SMR] scales [Figures 4-2 and 4-3].)
n At what age did you start your periods?
n When was your last normal menstrual period?
n What is the nature of your periods (e.g., frequency,
duration, amount of ow)?
Onset of Menstruation
The age range for menarche in the United States is
9 to 17 years. If the woman has had established
menses at intervals of every 21 to 38 days, then the
48 Chapter 4 • Amenorrhea
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Table 4-1
Ovary Involution of
Estrogen Diminution Progressive increase High
Progesterone Absent Absent Absent Appearing Rising Rising Decreasing
Endometrium Menstrual
Pituitary Secretion
Follicle-
stimulating
hormone
(FSH)
Luteinizing
hormone
(LH)
From Thompson JM, McFarland GK, Hirsch JE, Tucker SM: Mosby’s clinical nursing, ed 4, St Louis, 1997, Mosby.
Correlation of Ovarian and Endometrial Cycles (Ideal 28-Day Cycle)
EARLY
MENSTRUAL
(1-3 TO
5 DAYS)
corpus luteum
desquamation
and involution
Fairly constant until just before ovulation Moderate
Fairly constant until just before ovulation Marked
FOLLICULAR
(4 TO
6-8 DAYS)
Growth and maturation of graafian
follicle
Reorganization
and
proliferation
ADVANCED
FOLLICULAR
(9 TO
12-16 DAYS)
Further
growth and
watery
secretion
OVULATION
(12-16 DAYS)
Ovulation Active corpus luteum Involution of
concentration
increase just
before
increase just
before
EARLY LUTEAL
(15-19 DAYS)
Secondary rise Decreasing
Active secretion
and glandular
dilation
Rapid decrease in previous levels
Rapid decrease in previous levels
ADVANCED
LUTEAL
(20-25 DAYS)
Accumulation
of secretion
and edema
PREMENSTRUAL
(26-32 DAYS)
corpus luteum
Regressive
Chapter 4 • Amenorrhea 49
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Only the nipple is raised above
level of breast, as in child
1
M
1
Budding stage: bud-shaped
elevation of areola; on palpation, a
fairly hard "button" can be felt, disc-
2
3
4
5
or cherry-shaped; areola increased
in diameter and surrounding area
slightly elevated
M
2
Further elevation of mamma;
diameter of areola increased
further shape of mammary tissue
now visibly feminine
M
3
Increased fat deposits; areola forms
a secondary elevation above that of
breast; this secondary mound
apparently occurs in roughly half of
all girls, and in some cases persists
in adulthood
M
4
Adult stage; areola (usually)
subsides to level of breast and is
strongly pigmented
FIGURE 4-2 Five stages of breast development in females. (Photographs from Van Wieringen JC,
Wafelbakker F, Verbrugge HP, DeHass JH: Growth diagrams 1965 Netherlands: Second National Survey
on 0-24-year-olds, Groningen, The Netherlands, 1971, Wolters-Noordhoff; reprinted by permission of
Kluwer Academic Publishers.)
classication of secondary amenorrhea would apply.
Established menses indicate that there is no outlet
ow problem and that the HPO axis and endometrium are functioning.
Pubertal Development
Female pubertal development begins with a growth
spurt 1 year before the development of breast buds (thelarche) at around age 11 years. Then there is continued
growth for 1 year until the peak height velocity is
achieved. PH appears (pubarche), followed by axillary
hair and the beginning of menarche. The average age of
M
5
menarche for U.S. girls is 12 years 4 months. The length
of time from thelarche to menarche is 2 to 3 years.
A thorough review of pediatric growth charts is helpful
in determining the young girl’s norm of growth and
development and the centimeters attained by her latest
growth spurt. Most adolescent girls have a mean height
gain of 29 cm (11.4 inches) and the growth spurt lasts
approximately 4 years. Asking adolescents to self-identify
their Tanner SMR scales for breast and pubic maturity
provides very accurate staging (see Figures 4-2 and 4-3).
Additionally, it gives the opportunity for insight into their
feelings about their body and self-esteem.
50 Chapter 4 • Amenorrhea
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No growth of pubic hair
1
Initial, sparse, straight, downy, and slightly pigmented pubic hair, especially
along labia
2
Pubic hair is darker, coarser, and curly, and spread sparsely over entire pubis in
typical female triangle
3
Pubic hair is denser, curly, and in an adult distribution, but less abundant and
restricted to pubic area
4
Pubic hair is adult in quantity, type, and pattern, with lateral spreading to inner
aspect of thighs
5
Further extension laterally, upward, or over the upper thighs (this stage may not
occur in all women)
6
FIGURE 4-3 Tanner sexual maturity development in females. (Photographs from Van Wieringen JC,
Wafelbakker F, Verbrugge HP, DeHass JH: Growth diagrams 1965 Netherlands: Second National
Survey on 0-24-year-olds, Groningen, The Netherlands, 1971, Wolters-Noordhoff; reprinted by per-
mission of Kluwer Academic Publishers.)
Age of Menarche
The lack of menstrual periods and secondary sex
characteristics by age 14 or the lack of menses by age
16 in the presence of secondary sex characteristics is
considered primary amenorrhea. Fifty-six percent of
all adolescents start menses when PH development is
at PH stage 4 and 19% at PH stage 3 (see Figure 4-3).
If the adolescent is PH stage 4 but has not had a
menses, then primary amenorrhea should be diagnosed. However, if the adolescent does not meet the
age and maturation criteria, then suspect she is experiencing delayed puberty or is a so-called “late
bloomer.” She is likely to have a family history in her
mother and sisters of delayed menarche. Almost 80%
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